Hospital patients treated by older physicians are more likely to die

by on May 18, 2017 at 10:05 am in Economics, Law, Medicine | Permalink

BMJ: In a national sample of elderly Medicare beneficiaries admitted to hospital with medical conditions, we found that patients treated by older physicians had higher 30 day mortality than those cared for by younger physicians, despite similar patient characteristics. These associations were found among physicians with low and medium volumes of patients but not among those with high volumes.

…Our findings suggest that within the same hospital, patients treated by physicians aged <40 have 0.85 times the odds of dying (1.00/1.17) or an 11% lower probability of dying (10.8/12.1), compared with patients cared for by physicians aged ≥60 (table 2⇑). This difference in mortality is comparable with the impact of statins for the primary prevention of cardiovascular mortality on all cause mortality (odds ratio of 0.86)39 or the impact of β blockers on mortality among patients with myocardial infarction (incidence rate ratio of 0.86),40 indicating that our observed difference in mortality is not only statistically significant but arguably clinically significant. In addition, if our results are causal, an adjusted risk difference of 1.3 percentage points suggests that for every 77 patients treated by doctors aged ≥60, one fewer patient would die within 30 days of admission if those patients were cared for by physicians aged <40.

The paper has data on over 700,000 Medicare admissions and over 18 thousand hospitalist physicians. Physicians are assigned to patients more or less randomly depending on admission time so there are no significant differences between patients assigned to younger and older physicians. Older physicians are more likely to be male and, of course, to be trained during a different time period so the paper can’t fully distinguish age effects from cohort effects. The authors do find that older physicians who work a lot perform well–perhaps these physicians update their training or perhaps they are a self-selected vigorous sample. Continuing medical education and assessment requirements are probably very valuable.

Hat tip: Eric Topol.

1 prior_test2 May 18, 2017 at 10:10 am

Almost makes one wonder if an older doctor who is not cranking through a large number of patients is more sympathetic to a patient (who they may more likely see as an individual) who is not interested in living longer in pain.

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2 Thelonious_Nick May 18, 2017 at 11:05 am

Holy cow. Congratulations, prior_test2, on perhaps the first comment of yours I’ve ever read that I didn’t roll my eyes at. On topic, makes a good point, provides an alternative explanation.

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3 Floccina May 18, 2017 at 11:49 am

+1
Prior occasionally makes a good relevant comment. This is one of those occasions.

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4 Joe Torben May 18, 2017 at 1:26 pm

It’s an alternative explanation, but highly unlikely to be true. It is well known in the medical community that younger doctors are much better than older ones. The notable exception is surgeons where it’s the opposite. The reason is simply that younger doctors have more recent and better training. The surgeons, however, get good training at work every day, so being older means you have received more training.

As we know from how to be great at anything, it’s not practice, but deliberate practice. A major part of that is getting good feedback. Without feedback, it’s very hard to learn. Surgeons get immediate and to a high degree correct feedback after every operation. Most regular doctors get only anecdotal feedback.

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5 this actually makes sense if you read it twice May 19, 2017 at 12:45 am

I disagree, what Prior Dos says is likely to be true. Nobody is great at anything is a good first approximation when assessing variations within a profession that involves unpleasant work, which surgery is (did you know what really good surgeons do in the hours they are practicing on their own, outside of the general training path? It is not pretty. Seriously, imagine squirming immobilized (on a nasty day) or, thankfully, non-squirming dead (on a more humane day) rats and toads, for a starter. And that is just the starter, I don’t want to cause anyone who hasn’t thought about this much nightmares by commenting without warning in real detail about uber-real surgeons on an economics website. I think that (i.e., the general practice regimen of the typical top one percent surgeon) is wrong, even if it makes them better surgeons – but they are not going to listen to me no matter what I say. Prior Dos is right because – most people who have not been fired are competent until they try to do too much, quantity wise – the bottom fifty percent are generally spectacularly much worse than the top ten percent – but the top ten percent are almost never the ones who try to do too much, quantity wise. The bottom 90 percent know this and are humble and complacent enough about it to act the way Prior Dos said. The top one to ten percent do what they think is right regardless of the distribution of greater talent than their patients might ever have been exposed to on a less lucky or unlucky day for those patients (which – i.e., the distribution – they never ever think about, as Taylor Swift might say). If they think in their well educated little hearts of hearts that Patient X might as well go now as 10 years from now, they are not going to think too hard about it. Well, this world is structured in a way that allows love and goodness generally to prevail. Surgery is, after all, just surgery. So there’s that. Or maybe I just made all that up and nothing I said corresponds to the wonderful work being done in every hospital every day of the year, everywhere, for everybody, because every person is special to his or her doctor. (Imagine me writing this on a tablet, sitting at the DMV).

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6 Pshrnk May 18, 2017 at 11:32 am
7 Thanatos Savehn May 18, 2017 at 12:47 pm

Note the 30-day mortality rate for the entire cohort: 11.1%. This is obviously a group not showing up mostly for broken arms and forehead gashes from sliding into second base at the company softball game. These people were disproportionately suffering from longstanding, chronic, life-threatening conditions. You may well be right that the age 60+ docs (the lower end of whose CI is pretty close to that of the young whipersnapers btw) weren’t causing harm but instead had learned over the years that a good deal of heroic medicine is cruel foolishness.

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8 Joël May 18, 2017 at 3:23 pm

Very good observation.

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9 MikeW May 18, 2017 at 1:30 pm

Yep, when my 90-year-old mom was in hospital after hip replacement surgery, it wasn’t until day 4 that a gray-haired hospitalist asked her what they should do if they found her “unresponsive”. Mom, a retired nurse, said “Let me go”, very forcefully, the doc nodded and got her a wristband. I was amazed that nobody had asked that earlier in her hospital stay.

That was 3 years ago, Mom is still doing fine.

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10 Ted Craig May 18, 2017 at 10:18 am

This again raises the question of whether having people work longer is really the best solution to our growing retirement problem. Even in knowledge jobs, age can be a negative.

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11 Ignacio May 18, 2017 at 12:50 pm

But the alternative may not be replacing older with younger doctors. The alternative to not having older doctors may be not having doctors at all, which may be a worse scenario than a 11% probability of dying.

I also wonder if the allotment of patients is sufficiently random. It may be possible that patients in worse conditions will informally be assigned to more experienced (i.e., older) doctors, who may do a better job but still have many patients die. “more or less random” may not be sufficiently random to properly measure this effect.

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12 JFA May 18, 2017 at 10:20 am

Though, at some point, age effects and cohort effects wash out to roughly the same thing. Let’s say that it is only the new training that actually makes the difference in mortality differences. If it’s the case that older physicians just don’t keep up with advances in the field, then if there are any improvements in techniques in the future you are still going to want a younger doctor rather than an older doctor. Given that the AMA and the various licensing boards (which are most likely run by older doctors) they control, I don’t foresee extensive continuing education becoming a requirement any time soon.

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13 Slocum May 18, 2017 at 10:20 am

My initial reaction is you really don’t want to be treated by the older physician who’s transitioned to become mostly an administrator or committeeman with some medical practice on the side.

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14 Pshrnk May 18, 2017 at 11:38 am

+1

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15 GoneWithTheWind May 18, 2017 at 10:23 am

” the impact of statins”

What does that mean? Do they mean that taking statins is more likely to kill you or more likely to save you? Either way how does that directly relate to the doctors age? If my doctor prescribes statins and he is younger then 40 the statins work but if he is over 60 they don’t work!? Is this a real study or are you pulling my leg?

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16 Gil May 18, 2017 at 11:47 am

I took that as trying to provide a intuitive example so that people would understand the magnitude of the risks they discovered. “A younger doctor is as valuable as statins.”

…I think they failed though because I have no intuitive understanding of the value of statins in death risk reduction.

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17 GoneWithTheWind May 18, 2017 at 1:37 pm

I felt that they were reaching for anything to support their conclusion. I tend to believe that all or almost all “studies” like this intended to show specific results or confirm biases and that the underlying data and facts are weak. It may well be true that older (much older) doctors are not as up to date on modern methods and thus their patients die at slightly greater rates. I could actually believe the thesis. But in my opinion the author(s) held this bias when they began the study and surprise, surprise their study confirms their belief.

I am also reminded of that unfortunate incident in New York at a prestigious hospital where the head of the cardiac surgeons choose to operate on those patients who the other surgeons had rejected for the life saving operation because the patients condition made it likely that they would not survive surgery. The surgeon was using his greater skill in an effort to save the doomed patients. But no good deed goes unpunished. He was sued and his surgery survival record worked against him and he lost big and was forced out of practice. I can think of situations not too dissimilar that would explain why older doctors had a slightly larger number of patients who died that would have little to nothing to do with the doctors age. This study needs more research and perhaps it simple needs to be ignored.

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18 spencer May 18, 2017 at 10:29 am

It is just a comparison to but the study’s findings in perspective.

Satin have work and their positive impact is similar to the negative impact of older doctors.

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19 Axa May 18, 2017 at 10:31 am

Tyler is implying complacency.

Another perspective is that doctors retire until they want: “Norcross, who evaluates 100 to 150 physicians annually, estimates that about 8,000 doctors with full-blown dementia are practicing medicine. (Between 3 and 11 percent of Americans older than 65 have dementia.” http://alturl.com/4388b

There may be some interesting cognitive bias in doctors, feeling they’re immune to maladies because they study them.

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20 CL May 18, 2017 at 11:24 am

I doubt that Tyler implies anything, especially since the post is by Alex Tabarrok.

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21 Jay C May 18, 2017 at 11:32 am

rofl

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22 Axa May 19, 2017 at 7:04 am

Shit!

Anyway, what about the idea of old people with dementia still on practice?

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23 mavery May 18, 2017 at 10:33 am

The set of patients (“elderly Medicare patients”) makes me posit a alternative explanation:

Younger physicians are more comfortable prescribing treatments that extend life but do not improve the quality of life of their patients. You’re talking about a group of folks at risk of dying within 30 days of admission. For how many of them is that next month or whatever isn’t all that great. I speak as someone whose grandparents all died with vary levels of expediency. Those who lingered for months and years were not better off. Nor were their children and loved ones.

Maybe if you’re an older physician, you’re more free to be responsive to the real needs of your patients rather than needing to ensure you have good rates of billing or whatever it is hospitals use to evaluate your performance.

My point is that “30 day mortality rate among elderly Medicare patients” is not a criteria I’d ever use to evaluate physicians.

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24 Judah Benjamin Hur May 18, 2017 at 10:49 am

“My point is that “30 day mortality rate among elderly Medicare patients” is not a criteria I’d ever use to evaluate physicians.”

No, you definitely would consider it if the outcomes were dramatically different.

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25 mavery May 18, 2017 at 11:00 am

I’m pretty sure if there was a huge difference, there’d be another measure that would also show whatever’s driving that difference and do so in a more meaningful way.

But that’s pretty irrelevant to the topic at hand. If you want to disagree with me in a useful way, explain why you think this is a particularly meaningful measure in the context of the paper Alex has linked.

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26 Judah Benjamin Hur May 18, 2017 at 9:21 pm

And if you couldn’t find the other measure, you would unquestionably rely on the 30 day mortality rate when the difference goes beyond a certain point. For me, 11% is significant. You’re willing to ignore it because you think there may be a good reason to kill off some of the patients, but you don’t have any data on that. None. I could just as easily speculate that younger physicians (on average, of course) practice better hand hygiene.

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27 Jonathan May 18, 2017 at 2:31 pm

Unfortunately, one of the Medicare reimbursement methods *actually* used is readmission rate after discharge. (This measure is only used at a subset of hospitals.) The higher your sensitivity to the financial returns to the hospital, the more willing you’d be at the margin to have the patient die rather than leave and be readmitted. Unfortunately, 30 day mortality rates, while measured, do not have direct financial impact. (https://www.medicare.gov/hospitalcompare/Data/30-day-measures.html)

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28 Jonathan May 18, 2017 at 2:38 pm

Forgot to include the link showing that Medicare penalizes low preforming readmission rates but not low performing mortality rates. https://www.medicare.gov/HospitalCompare/linking-quality-to-payment.html

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29 Cyrus May 18, 2017 at 2:48 pm

Can you provide evidence that 30-day readmission and 30-day mortality are only weakly correlated?

Perhaps naively, I’m skeptical that one can practice cynical medicine in a way that patients are more likely to decline and die at home, but not more likely to decline and make it back to the hospital before dying, without crossing a real malpractice line.

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30 Jonathan May 18, 2017 at 4:03 pm

http://web.stanford.edu/~atulg/Gupta_JMP.pdf

The baseline estimates (Panel B) indicate that 30 day mortality has declined by 0.4 percentage point and this implies that moving a hospital from the 25th to the 75th
percentile [in readmission rates] is associated with a 0.35 pp (0.4*0.9, 3%) decrease in mortality. Note that the estimated effects are significant only at the 10% level.” So, weakly correlated.

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31 Jonathan May 18, 2017 at 4:09 pm

Re-reading Gupta’s paper reminded me that mortality rate *are* used as well in a different financial compensation measure, but in a much more attenuated way than readmission rates, whose effect is direct.

32 The Anti-Gnostic May 18, 2017 at 10:35 am

Just a thought. With the wisdom (cynicism?) of experience, older doctors may be less willing to prescribe treatments that extend life but do not improve quality of life for geriatric patients.

How Doctors Die

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33 The Anti-Gnostic May 18, 2017 at 10:42 am

Follow-up, we had two family members pass away after several weeks on ventilators. A pulmonologist later told me it is practically useless to ventilate elderly patients. Even if they (rarely) survive, they will be dead within a year.

After these two episodes, my 74-yo mother calls ventilation “billing.” I am under strict instructions from both my parents not to permit it in their cases.

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34 Hoonose May 18, 2017 at 11:08 am

You have got to look at this in the context of the individual patient. In the ’70’s elderly started at about age 70. Now it’s closer to 80-85.

And then you have to relate this to the patient’s reason for ventilation. If it’s respiratory failure due to progressing COPD, then the prognosis is indeed poor. But if it’s from trauma with a good chance of recovery then it is naturally done.

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35 The Anti-Gnostic May 18, 2017 at 11:24 am

One was pneumothorax from broken ribs, one was sepsis. The morbidity for ventilators is high. Your lungs use passive ventilation. Artificial ventilation is active and really rough on tissue. Most people over 60 won’t survive it.

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36 The Anti-Gnostic May 18, 2017 at 11:27 am

Sorry for being pedantic, Doctor.

I looked up the morbidity rates after the second family member passed away. Seems to be very limited utility for elderly patients.

37 Slocum May 18, 2017 at 12:04 pm

I would generally agree, but I have an elderly relative who was recently necessitated and put on a ventilator. After a rough few weeks, she recovered and is now back in her apartment feeling better than she did before her episode. She may die within a year, but then she is in her 90s.

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38 Judah Benjamin Hur May 18, 2017 at 10:46 am

Perhaps, but I’m now going to be biased in favor of younger doctors.

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39 prior_test2 May 18, 2017 at 11:11 am

And if you spent 7 years of your life unable to move and on a ventilator (of the variety where regular lung suction is required), who knows, you just might change your mind in the 8th year.

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40 Judah Benjamin Hur May 18, 2017 at 9:01 pm

Oh sure, if I WANT to die then I might use different criteria for choosing a physician!

There is no evidence that the difference in outcomes can be explained by older doctors providing this kind of “assistance.”

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41 Per Kurowski May 18, 2017 at 10:39 am

Are we to have two lanes in the emergency room? One with younger doctors and higher toll and one with older ones but lower tolls?

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42 Hoonose May 18, 2017 at 11:01 am

We haven’t had an older doc in the ER in a long time.

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43 Per Kurowski May 18, 2017 at 11:21 am

What do you mean… you do not offer a choice? 🙂

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44 Hoonose May 18, 2017 at 11:50 am

I’m no longer involved. But our hospital contracts with such and such ER doc group, and they just don’t seem to have older ER docs anymore. This is my local experience, but I doubt that many older docs elsewhere are working ER’s these days.

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45 Bill May 18, 2017 at 10:43 am

I always knew that Dr. Oz was bad for your health, but not Dr. Welby. Say it isn’t so.

The CEO of a staff model HMO I represented used to say the biggest predictor of how you would be treated by a doctor was when and where the doctor was first taught and trained. He believed that a staff model HMO, which standardized medical practice to current standards, resulted in better outcomes than individual practitioners since doctors would be retrained and monitored to follow standardized procedures and protocols. They did a lot of data collection and worked with other systems in developing best practices.

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46 Hoonose May 18, 2017 at 11:00 am

As an older doc about to retire, I can tell you that when I came to my small town in 1981, if you were sick you did not want to have the older docs in town care for you in the hospital. I gradually exited my hospital practice as I aged, and didn’t keep up. I suspect something similar is going on today.

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47 JWatts May 18, 2017 at 11:50 am

“In a national sample of elderly Medicare beneficiaries admitted to hospital with medical conditions, we found that patients treated by older physicians had higher 30 day mortality than those cared for by younger physicians,”

It would be nice if they showed the actual mortality instead of bracketing into an arbitrary bucket. And the costs involved for the actual patient.

If under 40 physicians average 50 days for $200K in costs and over 60 physicians average 25 days for $25K in costs, then it becomes a different argument.

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48 Doctor D May 18, 2017 at 12:03 pm

Patients are not randomly assigned in the hospital. Evening/overnight shifts are disproportionately staffed by younger physicians…this is true at most hospitals. This non-random selection error is not insignificant. Hard to believe they didn’t account for that.

However, you see this to the extreme in the military. The best doctors by far are the captains (O3) and Majors (O4s). Doctors who stay in the military to reach Colonel spend 75% of their time doing paperwork…and it shows.

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49 regularjoeski May 18, 2017 at 2:09 pm

The above can not be emphasized enough. Patients are not randomly assigned. Also, the authors age distribution smacks of probable data manipulation. The study should have been cohorts of years past med school graduation. Also, as others have posted if you are >60 and admitting hospital patients something else is going on. Being a hospitalist is a young person game. Why work nights if you do not have too? The correlation was found in low volume MDs, not high volume MDs. Click baiting data manipulation.

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50 Adam May 18, 2017 at 12:16 pm

Could it be that doctors who are any good eventually find something more profitable to do than treat random old people coming into hospital?

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51 Hoonose May 18, 2017 at 3:40 pm

Early in the ’90’s as a practicing internist I began to realize that I could make good money just from the office. Minus all the 24/7 hassles of inpatient work. I used to be a really good doc.

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52 Thiago Ribeiro May 18, 2017 at 12:20 pm

Old people, what are they good for? I say, we kill them and take their golden teeth.

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53 msgkings May 18, 2017 at 2:24 pm

This is typical Brazilian savagery.

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54 Thiago Ribeiro May 18, 2017 at 4:26 pm

It is neither typical nor savagery.

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55 JWatts May 18, 2017 at 7:42 pm

I notice that you didn’t deny the Brazilian connection though.

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56 Thiago Ribeiro May 18, 2017 at 8:00 pm

It is Brazilian because I am Brazilian. And, as a famous Brazilian leader said, I am a jaguar.

57 Behrang May 18, 2017 at 12:26 pm

If older docs’ patients all died on day 29 and younger docs’ patients died on day 31, we’d have the same conclusion. The issue of clinical significance could have been nicely demonstrated by mentioning the difference in days or a Kaplan-Meyer plot. Instead, the authors use the statin analogy. Makes you wonder what the clinical significance of this difference is. Or, am I missing something?

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58 mavery May 18, 2017 at 2:11 pm

I thought the statin analogy was a good one. When you do statistical analyses, its often difficult to contextualize the results in a way that directly meaningful to the lay person. Statins are a class of drugs many folks are familiar with, and they have a widely recognized utility. By comparing the impact of their result to the impact of statins, the authors give a less precise but far more easily recognizable and understandable description of their result.

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59 Decolliber May 18, 2017 at 12:59 pm

Unless you are in hospital for an emergency, you have some choice over your doctor. The patients most likely to die are the older ones, who may also be more likely to believe that they will get better treatment from a “more experienced” (ie, older) doctor. Insofar as people associate age with wisdom, the more seriously ill you are, the more likely you are to chose an older doctor. Also, perhaps the “old doctors will kill you” hypothesis needs to control for different areas of medicine. Having seen several ophthalmologists over the past ten years I have received much better vision correction treatments from older than younger ones.

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60 Atul Gowande May 18, 2017 at 10:15 pm

Doctors are okay but for many, many specialties you are looking at manufactured consent type jobs. The same as “account managers” at Google and “engagement managers” at Booz Allen and “associates” at Banks. College proficiency in subdued docility, long hours for first four years following orders, excel sheets and other procedures, then a lot of money for not much more work and a lot of delegation. Doctors are overvalued.

Life expansion occurred in the 20th century. The rate has dissipated b/c of complacency and crooks.

“You don’t want your federal government fixing a broken knee or even a broken back.” Trump

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61 john May 19, 2017 at 8:20 am

“Continuing medical education and assessment requirements are probably very valuable.” now there is a sentance to ponder. Did we really need a study to get to that point? Or is that more about the need for such a study to get the licensing and industry groups to realize that their world is one of ongoing changes that can quickly obsolite prior knowledge.

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